Burn Management

Aka: Burn Management, Parkland Formula for Fluid Resuscitation in Burn Injury

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II. Management: Home interventions for patients prior to presentation

  1. Do not break Blisters
  2. Do not apply any topical medications to burn site prior to evaluation
  3. Immediately remove any items that may cause further injury
    1. Remove all clothing, jewelry, Contact Lenses
    2. Stop any ongoing burning
  4. Consider placing the wound site under cool Running water for 20 minutes (minor Burn Injury only)
    1. May reduce Burn Injury depth and allow for faster healing with less scar
    2. Benefits may be limited to the following one hour
  5. Do not immerse the burn in ice water
    1. However cool burn with water
    2. Risks further injury and Hypothermia

III. Management: General Pointers

  1. Use Opioids intravenously (avoid intramuscular use)
    1. Administer adequate analgesia to allow for assessment, cleaning and dressing of wounds
  2. Avoid antibiotics until infection occurs
  3. Administer tetanus Vaccination
  4. Do not cover burns with Silvadene if transporting
    1. Obscures lesions for primary burn team
    2. Burn team will apply Silvadene after their evaluation
    3. Bacitracin may be applied

IV. Management: Initial

  1. Trauma Primary Survey
    1. Assess airway Inhalation Injury
      1. Assess airway edema (intubate if suspect unstable airway)
      2. Arterial Blood Gas (ABG)
      3. Carboxyhemoglobin
        1. Dive Chamber indicated for level >40
    2. Remove all clothing, jewelry, Contact Lenses
    3. Stop any ongoing burning
    4. Cover injured areas after evaluation to prevent overall body heat loss
  2. Trauma Secondary Survey
    1. Assign Burn Injury grading and surface area involved
    2. Assess other injuries
    3. Evaluate for signs of intentional injury (e.g. abuse)
    4. Consider Smoke Inhalation and complications (Carbon Monoxide Poisoning, cyanide Poisoning)
    5. Evaluate for Compartment Syndrome requiring escharotomy
      1. Escharotomy may be deferred to Trauma surgery if good doppler pulse on Ultrasound at transfer time
      2. Compartment Syndrome onset >2 hours after Burn Injury (typically 4-6 hours)
        1. Orgill (2009) J Burn Care Res 30(5): 759-68 +PMID:19692906 [PubMed]
  3. Assess Fluid status
    1. Urine Output minimums
      1. Adult: 30-50 cc per hour
      2. Child: 1 cc/kg per hour
    2. Intravenous requirements for insensible loss (Parkland Formula)
      1. Parkland formula applies to burns encompassing >20% BSA
        1. First Degree Burn area does not count toward percent burn area or fluid volume
      2. Administer 2-4 ml crystalloid (NS or LR) per kg per %BSA
        1. Lactated Ringers (LR) is preferred to avoid hyperchloremic Metabolic Acidosis
          1. Volume requirements over first 24 hours may be as much as 10-20 Liters
        2. No initial fluid bolus is needed unless hypotensive
        3. Exercise caution in burn percentage calculation in children (overestimated by >200%)
          1. Goverman (2015) J Burn Care Res 36(5): 574-9 +PMID:25407387 [PubMed]
      3. Divide rehydration over 24 hours
        1. Give 50% over first 8 hours since burn
        2. Give second 50% over next 16 hours

V. Management: Wound Care

  1. Avoid scrubbing the wound with antiseptics (e.g. Betadine, Peridex, Hibiclens)
  2. Use sterile saline or sterile water to clean the wound and eliminate debris
  3. Blisters
    1. Blister fluid contains both cytokines that cause inflammation, but also growth factors to speed healing
    2. Indications to debride
      1. Debride roofs of large Blisters with thin walls
        1. Allows dressings to be applied to wound directly
      2. Debride roofs of Blisters overlying joints
        1. Allows for normal joint movement
    3. Blister debridement approach
      1. Unroof Blister with sterile scissors
      2. Clean wound with chlorhexidine or similar mild antibiotic soap
      3. Cover wound with ointment and nonadherent dressing
    4. Indications to NOT debride
      1. Small Blisters (<6 mm) should be left intact
      2. Large thick walled Blisters (aspirate instead)

VI. Management: Topical agents

  1. Goal is to maintain moist healing environment and prevent infection
  2. Avoid Topical Corticosteroids
  3. Topicals for superficial burns (first degree)
    1. No treatment needed (will heal without intervention within 1 week)
    2. Aquaphor
    3. Bacitracin ointment
    4. Honey
    5. Aloe vera (may reduce pain)
    6. Topical NSAID (e.g. Diclofenac Gel, may reduce pain)
  4. Topicals for partial thickness burns
    1. Topical Antibiotics
      1. Bacitracin ointment
        1. Preferred initial topical agent in most cases
      2. Mupirocin (Bactroban)
        1. Used for MRSA prone regions (e.g. facial burns around the nose)
      3. Mafenide acetate (Sulfamylon)
        1. Used for deep burns even if eschar present
      4. Silvadene (Silver Sulfadine, SSD)
        1. Do not apply if Transferring patient to burn center (obscures wound)
        2. Preferred in Third Degree Burns
        3. Other agents are preferred for Second Degree Burns
          1. Silvadene inhibits Keratinocyte replication and delays healing and increases scar risk
          2. Wasiak (2013) Cochrane Database Syst Rev 3:CD002106 +PMID:23543513 [PubMed]
        4. Contraindicated in Sulfa Allergy, G6PD, pregnancy and Lactation and newborns
        5. New Occlusive Dressings may offer faster healing, less pain and lower cost (e.g. Aquacel Ag)
    2. Absorptive Dressings
      1. Aquacel Ag
        1. Less pain and healing time as well as less frequent dressing changes
        2. Lower total cost than Silvadene
        3. Broad spectrum antibacterial coverage
      2. Hydrocolloid Dressings (Duoderm, urgotul)
        1. Form gel when moisture is present (absorbs exudates)
        2. Less pain and healing time
        3. However dressing has an odor and obscures visualization of the wound site
      3. Alginate Dressings
        1. Seaweed derived absorbtive dressings
    3. Nonabsorptive dressings
      1. Nonadherent gauze (e.g. Vaseline Gauze)
        1. Inexpensive dressing used for superficial burns; lacks antibacterial coverage
      2. Silicone (Mepitel)
        1. Expensive dressing that allows wound seepage to pass through to overlying bandage
      3. Silver Impregnated dressing (e.g. Acticoat)
        1. Expensive non-adherent dressing that has broad spectrum antibacterial coverage
      4. Foam Pads (e.g. Optifoam)
        1. Barrier protection of wound site
    4. Miscellaneous dressings
      1. Biocomposite or biosynthetic (e.g. Biobrane)
        1. Silicone membrane with nylon mesh
        2. Efficacy limited to superficial burns and is expensive
      2. Bioactive skin substitute (e.g. Trancyte)
        1. Expensive, but less pain and healing time and allows visualization of burn through the dressing

VII. Management: Infection

  1. Causes
    1. Staphylococcus aureus
    2. Streptococcus Pyogenes
    3. Pseudomonas aeruginosa
    4. Acinetobacter species
    5. Klebsiella species
  2. Precautions
    1. Signs of Iinfection may be difficult to distinguish from the original burn inflammation
    2. Infections at burn sites may progress rapidly
    3. Oral antibiotic prophylaxis (e.g. Cephalexin) is NOT recommended in first or Second Degree Burns
      1. Systemic antibiotics do not modify skin surface flora and do not reduce infection risk
      2. Topical Antibiotics may reduce infection risk
    4. Foot burn injuries in Diabetes Mellitus are high risk for infection (15%)
      1. Clinical re-examination of feet every 3-4 days is recommended (or admit for 3-4 day observation)
  3. Management
    1. Direct antibiotics coverage to Gram Negatives and Gram Positives based on local Antibiotic Resistance

VIII. Management: Criteria for transfer or referral to burn center

  1. Partial thickness burns involving more than 10% of total body surface area
    1. Immediate transfer if partial thickness burn involving 20% BSA (10% if age under 10 or over 50 years old)
  2. Third degree (full thickness) burns
    1. Immediate transfer if Third Degree Burn >5% of total body surface area
  3. Any burns of high risk areas
    1. Face, eyes or ears
    2. Hands or Feet
    3. Genitals or perineum
  4. Electrical Burns
  5. Inhalation Injury
  6. Chemical burns
  7. Burn Injury with associated Trauma (e.g. Fractures)

IX. Management: Burn-related symptoms

  1. Pruritus
    1. Cetirizine (Zyrtec)
    2. Doxepin topically
  2. Pain
    1. Opioid Analgesics
    2. Gabapentin (Neurontin) or Pregabalin (Lyrica)
  3. GI prophylaxis (peptic ulcer prophylaxis)
    1. Consider H2 Blocker (e.g. Ranitidine) or Proton Pump Inhibitor (PPI) for more hospitalized patients with Burn Injury

X. References

  1. Mason and Yowler in Herbert (2016) EM:Rap 16(4):4-5
  2. Cuttle (2009) Burns 35(6): 768-75 [PubMed]
  3. Grunwald (2008) Plast Reconstr Surg 121(5): 311e-9e [PubMed]
  4. Hettiaratchy (2004) BMJ 328(7452): 1366-8 [PubMed]
  5. Lloyd (2012) Am Fam Physician 85(1): 25-32 [PubMed]
  6. Roberts (2003) Emerg Med News 25(3): 28-31 [PubMed]
  7. Sheridan (2005) Emerg Care 21(7): 449-56 [PubMed]

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Related Studies (from Trip Database) Open in New Window

Ontology: Burns care (C1318600)

Concepts Biomedical Occupation or Discipline (T091)
SnomedCT 408462000
English burn management, burns managements, burns management, management burns, Burns care (qualifier value), Burns care, Burns management
Spanish atención de quemaduras (calificador), atención de quemaduras
Derived from the NIH UMLS (Unified Medical Language System)

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